Continuous Local Antibiotic Perfusion Reduces Failure and Unplanned Reoperation in Fracture-Related Infection: Expanded Multicentre Study

Introduction & Aim Fracture-related infection (FRI) remains a major challenge, requiring both infection control and preservation of fixation and fracture healing. With advances in treatment strategies, evaluating treatment outcomes only by eventual infection control may be insufficient. Clinical benefit may be better reflected by reductions in treatment failures, unplanned procedures, and overall treatment burden. Continuous local antibiotic perfusion (CLAP) is a local drug-delivery strategy designed to achieve high antimicrobial concentrations directly at the infected site. Using an expanded multicenter FRI dataset, this study aimed to investigate whether CLAP was associated with improved clinical course in surgically treated FRI. Methods We conducted a multicenter retrospective observational study of patients who underwent surgical treatment for FRI between January 1, 2019 and December 31, 2023. Cases involving fingers, toes, ribs, or spine, as well as those undergoing prosthetic joint replacement or having a follow-up period of less than 1 year, were excluded. A total of 334 patients were included, of whom 196 received CLAP and 138 were managed without CLAP according to institutional treatment strategy. Baseline characteristics, treatment variables, and clinical outcomes were retrospectively reviewed. Outcomes of interest included treatment failure, recurrence, reoperation, and acute kidney injury (AKI) as safety outcomes. Treatment failure was defined as recurrence, unplanned reoperation (e.g., debridement, local antibiotic therapy, implant removal, amputation, arthrodesis, or nonunion surgery), or persistent infection at final follow-up. Results Treatment failure occurred less frequently in patients treated with CLAP than in those managed without CLAP (26.0% vs 46.4%, p<0.01). Unplanned surgery was also less frequent in the CLAP group (24.5% vs 43.5%, p<0.01), as were additional debridement procedures (7.7% vs 18.1%, p<0.01) and additional local antibiotic procedures (9.2% vs 25.4%, p<0.01). Recurrence was lower in the CLAP group (10.7% vs 18.8%), although the difference did not reach statistical significance (p=0.05). The total number of surgeries was lower in the CLAP group (2.4±2.0 vs 2.9±2.4, p=0.05). There were no significant differences in implant removal, amputation, arthrodesis, nonunion surgery, or AKI (8.7% vs 7.2%, p=0.79). Conclusions In this expanded multicenter retrospective observational study, CLAP was associated with reduced treatment failure and fewer unplanned reoperations in surgically treated FRI, without increasing AKI. These findings suggest that CLAP may help achieve infection control more efficiently, with fewer additional procedures on the way to treatment completion.